PLEASE COMPLETE ALL COMPULSARY * FIELDS
Your details

* Name:

* Surname:

* Age: 

* Birthday:

Postal address:  

Residential address:

Work address:

* Email address: 

* Mobile number: 

Home number: 

Work number: 

Help us know & understand you, so we can tailor-make Kingfisher FM to you

Gender: 

male   female

Home Language:

English   Afrikaans    Xhosa  Other

Education:

Primary    Secondary    Tertiary

I earn:

0 - R10 000   R10 000 - R20 000   < R20 000

I am on Facebook:

yes    no

I am on Twitter:

yes    no

I am on Skype:

yes    no

I belong to a gym:

yes    no

I shop at:

Spar    Checkers    Pick n Pay    Other

I am a member of:

Lions International    Rotary International    Other

I belong to a church:

yes    no   If 'yes' church name:

I have children:

yes    no   If 'yes' how many?
If 'yes' and they are still at school, which school:

I belong to a medical aid:

yes    no    If 'yes' which one?

I go to movies at:

Walmer Park    The Bridge    The Boardwalk    Fountains Mall

I own a car:

yes    no    If 'yes' what make is it:   
If 'no' how do you travel:  bus    taxi   other

I do charity work:

yes    no    
If 'yes' provide details: 

I watch these TV channels:

SABC    Top TV    E-TV    DSTV

I watch these movies/dvds:

Christian    Comedy    Action    Drama    Romance

I read:

Not at all    Newspapers    Magazines    Fiction    Non-fiction    Christian

I am:

Married    Single    Engaged    Divorced    Other

* SUBSCRIPTION & DEBIT ORDER AUTHORITY

With my confirmation below I subscribe to Kingfisher FM’s ‘LISTENER LOYALTY PROGRAM’ and wish to receive a Kingfisher FM FAMILY LIFESTYLE CARD with all its benefits and obligations. Please send me regular information on discounts, new advertisers, promotions & competitions. Also please include me in any surveys which the station may do from time to time in order that I may have my say with regards to Kingfisher FM’s music, programming &content. With my/our confirmation below Kingfisher FM is authorised to draw against my/our account, as per the bank details below (or any other bank or branch to which I/we may transfer my/our account), the sum of R50 per month as monthly subscription fee on the * 6th or 20th of each month. All such withdrawals from my/our account by Kingfisher FM shall be treated as though they have been signed by me/us personally. This authority may be cancelled by me/us by giving Kingfisher FM thirty days notice in writing. I/we understand that I/we shall not be entitled to any refund of amounts of which Kingfisher FM has withdrawn while this authority was in full force if such amounts were legally owing to Kingfisher FM. Receipt of this instruction by Kingfisher FM shall be regarded as receipt thereof by my/our bank (whichever it is or will be).

* I confirm that I am in agreement with the above debit order authority:

* Bank:

* Account name:

* Branch:

* Branch number:

* Account type:

current    savings    transmissions

* Account number: